Older women who wish to concieve have to figure out if they require IVF, and whether they need donor eggs. The Clomiphene Citrate Challenge Test is very useful in these situations.

Many older infertile women are very unsure as to whether they need to do IVF; and if they do need IVF, if they should use their own eggs or to use donor eggs. While they understand with their heads that using donor eggs would maximise their chances of getting pregnant, it's hard for their heart to accept this decision, because most of us want a genetic link with our child !

How the confusion occurs 

This is especially true for older women who have regular cycles; grow follicles on ultrasound scans, or have had a miscarriage in the last 2-3 years. If my cycles are regular and I can get pregnant in my own bedroom, doesn't this prove my eggs are fine?

Gynecologists (who do not specialise in infertility treatment) will often add to this confusion. Because they see 42 year old women who get pregnant in their own bedroom, they fail to understand there is a big difference in the biology of a fertile 42 year old and an infertile 42 year old. They will often "treat" these older women with clomiphene and follicular monitoring - causing them to waste valuable time!

The more sophisticated doctors will get their patient's FSH levels tested - and if these are normal, this will lull them into a false sense of security! Not only are FSH levels very poor markers of ovarian reserve, they also vary from month to month; and if they are checked without also testing the estradiol ( E2) level at the same time, you may get an apparently normal FSH level, even if the ovarian reserve is very poor. (A high E2 level can suppress a high FSH level into the normal range, and fool both doctor and patient !)

Unfortunately, most older women do not want to hear bad news. They are often in a state of denial and are not happy to listen to an IVF specialist who tells them that their "eggs are bad"! They confuse calendar age with ovarian age - and are even more perplexed when they go online and read success stories of older women with high FSH levels who have got pregnant in their own bedroom !

Who should they trust ? Is the IVF doctor pushing IVF because he wants to make more money ?
Or is he providing medically sound advise ? Will you regret not doing IVF ? Or do you have an equally good chance of making a baby in your own bedroom ? And what if the IVF cycle fails ? Then what ?

While it's true that we do have better tests today for checking ovarian reserve, such as the AMH level and the antral follicle count , it's hard to make such an emotionally charged decision based purely on the results of medical tests. How reliable are these tests ? Can the results improve with alternative medicine? herbal supplements? acupuncture?

If you are unsure about what to do, and are emotionally detached enough to make a decision based purely on medical testing, then please ask your doctor to do a clomiphene citrate challenge test ( CCT) for you.

This is a simple , inexpensive test, that provides very valuable information; and has stood the test of time. When it's hard to make a decision and you are confused, sometimes basing your decision on an objective test result can help you overcome your paralysis and move on with your life !

How does one do this test ?

  • Day 1 = day the bleeding of the period starts
  • On Day 3 , you need to do a blood test to measure your levels of FSH,LH,PRL and TSH; and AMH ( anti-mullerian hormone). Do this from a reliable lab please
  • Take 100 mg clomiphene citrate from Day 5 - Day 9
  • Repeat the blood test for FSH again on Day 10
  • If the Day 3 plus Day 10 FSH levels are less than 25, then we can try to do IVF with your own eggs
  • If the Day 3 plus Day 10 FSH levels are more than 25, this suggests you have ovarian failure, and that donor egg IVF would be your best treatment option, if you are willing to consider this. A low AMH level will help to confirm this diagnosis.

The right decision at the right time

For the older woman, time is now at a premium for you - please don't waste it ! When you are 60 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. Treatment can be expensive, but a baby is priceless !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Not happy with the attention you are getting from your IVF clinic? Need more information? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you!

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.

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